Question about TBI w/ cranioectomy?

[jadespirro]

i hope someone can answer these questions. first i am not sure i have the right term but here we go. pt was in a severe mva, had part of his skull removed to help relieve the pressure, also had a shunt put in. even with these measures he is building too much fluid. (hydrocephalus) when looking at his head, it looks like the brain has fallen to the side about ear level. is this normal? when giving a bed bath, i felt the tissue around there and it is very mushy. is that normal? if any one can give me some understanding it would be much appreciated. this is my first semester of nursing school. i want to understand what these findings mean if anything.

[JentheRN05, RN]

Hopefully the patient was bandaged up at the site and what you were seeing was partly bandage. Hydrocephalus commonly will result in a swelling at the part of the brain that is the 'path of least resistance' so, with the craniotomy the hole that was made in the skull to relieve pressure is actually doing it's job. The extra fluid does have a place to go rather than compress inside the skull, which could lead to brain stem herniation and death. The shunt acts as a faucet switch sort of, to release pressure from the inside of the skull by removing fluid. It would be slightly 'mushy' of course because what you are feeling is similar to edema, when you feel edema (+2 or more pitting) on a patient, it is 'mushy' too. So all of these findings are probably quite normal.

[Elenaster]

If a bone flap was removed to allow more room for the brain to swell, it's very possible there is an area with no protection to the brain tissue itself. This procedure is often resevered as a "last ditch" measure for hydrocephalus refractory to other treatments (shunt, mannitol, etc.)

I have heard this commonly, (albeit inappropriate) called "mush head." The nurse is responsible for protecting the area, much as you would the fontanels in an infant.

[MS._Jen_RN, ASN, RN]

This is normal although the part that you see "flopping to the side" is likely not brain tissue itself but crainal tissue engorged with CSF. Obviously the shunt is not doing the job fully, and as a previous poster said, the crainectomy is often a last ditch effort to prevent brain stem herniation. Often the swelling will subside and the bone flap isreplaced. It is often stored in the patients abdomen or a bone bank until this is done.

Also, as prevous poster indicated it is very important to protect the head because of potential of trauma directly to the brain. Often our patient will be required to wear a helmet when out of bed or participating in and transfer or therapy.

~Jen

[jadespirro]

heres a little more info. on the scene had a gcs score of 3, depressed scull fracture, subdural hematomas, subarachnoid hemorrhage. underwent hemicraniectomy, evacuation of hematomas, shunt was placed, trach (for respiratory failure) and peg. these procedures were done approx two months ago. no bandages in place. eyes open but no tracking- pupils fixed and dilated. yawning, and coughing w/ no sound. bone flap to be replaced w/ in a week. do pts. like this get better? what do you call this state? are the meninges removed w/ the skull? is their a good internet source for information like this?

[MS._Jen_RN, ASN, RN]

I'll try to answer your questions.

1- do patients like this get better? Yes, they can. (Here comes the "BUT") But,the longer a person is unresponsive and/or in post traumatic amnesia the less likely they are to ever live independently. Given your description, at 2 months post injury, the prognosis for a functional recovery is slim to none. (another "BUT") But, good things do happen. The brain is a funny thing like that. Age also affects prognosis. Younger=better recovery.

2- what is that state called? There are several terms, the most common is "persistant vegatative state".

3- Are the meniges removed/ cut open? I'm really not sure. I'm guessing with your guy they are probably ruptured from the trauma. That is a really good question. I'll see if I can find out.

4- Good website- there are several oriented toward family of TBI patients. I'm not sure about oriented toward medical personel.

(He coughs and yawns with no sound 'cause of the trach. He can't move air past his vocal cords)

If you have any more questions feel free to post here or PM me.

~Jen

[jadespirro]

Thank you!!! Don't I feel silly not thinking about the lack of sound...DUH! Brain overload I guess...

[MS._Jen_RN, ASN, RN]

It happens to the best of us. :chuckle

My first patient was a Pt with a TBI. I will never forget him. I have since had the chance to work with many on an acute care rehab floor. I love it. There are many "good" stories to balance the "bad". You learn to drive carefully and sober, always wear a helmet on a bike or motorcycle, and be careful in high places. A good brain is a terrible thing to scramble.

~Jen